=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821152133
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRI JO GILLETTE D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 09/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1013 LIBERTY ST APT. 104 D
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-941-5117
-----------------------------------------------------
Fax | 815-941-5118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1745 LITTLE WILLOW RD
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-6849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-941-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038010842
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------